Faculty Bibliography

OBJECTIVES:Our objectives were (1) to use in situ simulation to assess the clinical environment and identify latent safety threats (LSTs) related to the management of pediatric tracheostomy patients and (2) to analyze the effects of systems interventions and team factors on LSTs and simulation performance. METHODS:A multicenter, prospective study to assess LSTs related to pediatric tracheostomy care management was conducted in emergency departments (EDs) and intensive care units (ICUs). LSTs were identified through equipment checklists and in situ simulations via structured debriefs and blinded ratings of team performance. The research team and unit champions developed action plans with interventions to address each LST. Reassessment by equipment checklists and in situ simulations was repeated after 6 to 9 months. RESULTS:Forty-one LSTs were identified over 21 simulations, 24 in the preintervention group and 17 in the postintervention group. These included LSTs in access to equipment (ie, availability of suction catheters, lack of awareness of the location of tracheostomy tubes) and clinical knowledge gaps. Mean equipment checklist scores improved from 76% to 87%. Twenty-one unique teams (65 participants) participated in the simulations. The average simulation score was 6.19 out of 16 points. DISCUSSION:In situ simulation is feasible and effective as an assessment tool to identify latent safety threats and thus measure the system-level performance of a clinical care environment. IMPLICATIONS FOR PRACTICE:In situ simulation can be used to identify and reassess latent safety threats related to pediatric tracheostomy management and thereby support quality improvement and educational initiatives.

OBJECTIVES/OBJECTIVE:Intravenous (IV) ibuprofen was approved by the FDA for use in pediatric patients in November 2015. The objective of this study was to compare bleeding rates in pediatric tonsillectomy patients who received intraoperative intravenous ibuprofen versus those who did not. Secondary objectives included analyzing factors that correlated with return to the Emergency Department (ED) for pain or dehydration. METHODS:Charts were reviewed for all patients 0-18 years of age who underwent a tonsillectomy with or without adenoidectomy at a tertiary care children's hospital from 1/1/2017 through 5/21/2018. Demographic information and perioperative medications including the use of intraoperative intravenous ibuprofen were recorded. ED visits and operating room (OR) returns for bleeding were tracked for up to 30 days after surgery. RESULTS:1085 charts were analyzed. Intraoperative IV ibuprofen was used in 132 cases (12.2%). Primary bleeds, defined as bleeding within 24 h of surgery, occurred in 1 (0.76%) of 132 patients who received IV ibuprofen, and 1 (0.10%) of 953 patients who did not receive IV ibuprofen. Secondary bleeds, defined as bleeds after 24 h from surgery occurred in 2 (1.52%) of 132 patients who received IV ibuprofen and 38 (3.99%) of 953 patients who did not receive IV ibuprofen. No statistical difference was found between the two groups in rates of overall (primary plus secondary) bleeding requiring return to ED (p = 0.759) or return to OR (p = 0.710). CONCLUSION/CONCLUSIONS:The observed bleeding rate after pediatric tonsillectomy was not statistically different in patients who received intraoperative IV ibuprofen versus those who did not receive this medication. LEVEL OF EVIDENCE/METHODS:III.

OBJECTIVES:To assess the independent relationships of obesity and obstructive sleep apnea (OSA) with hypertension/elevated blood pressure (EBP) in adolescent patients. STUDY DESIGN:A retrospective cohort analysis was performed on 501 patients (age 13-21 years) with three separate blood pressure measurements within 6 months of polysomnography. EBP was defined as average systolic blood pressure (SBP) ≤120 mm Hg; obesity as body mass index Z-score ≤1.65; and OSA as obstructive apnea-hypopnea index <1. Pearson correlations and multivariable analyses were performed to assess the independent effects of the apnea-hypopnea index and body mass index Z-score on SBP. RESULTS:Of 501 patients (mean age 16 ± 2 years), 246 (49%) were male. OSA was present in 329 (66%) patients, obesity in 337 (67%), and EBP in 262 (52%). EBP was present in 70% of obese adolescents and 60% of adolescents with OSA. Univariable correlation showed a significant relationship between SBP, body mass index Z-score, and apnea-hypopnea index. Multivariable linear regression analysis showed blood pressure was significantly associated with body mass index Z-score (β = .46; P < .01), age (β = .25; P < .01), and height Z-score (β = .14; P < .01), but not apnea-hypopnea index (β = .01; P = .72). CONCLUSIONS:The relationship between OSA and EBP in adolescents is most closely associated with the degree of obesity. Further studies are needed to assess the effect of the treatment of obesity and OSA on blood pressure in adolescents.

OBJECTIVE:Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery. METHODS:We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status. RESULTS:Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention. CONCLUSION/CONCLUSIONS:With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.

OBJECTIVES/OBJECTIVE:ties was hypothesized to differ from those in patients with twill ties. METHODS:ties. Patients were followed for the first seven postoperative days. The primary outcome was skin-related complications, which were further categorized into mild (irritation) and severe (breakdown). The secondary outcome was accidental decannulation. Rates of skin-related complication and accidental decannulation were compared across the two groups using chi-square analysis. RESULTS:ties was associated with a decreased rate of skin irritation (OR: 0.41; 95% CI: 0.17-0.97; P = 0.039). CONCLUSIONS:ties at the time of pediatric tracheotomy placement.

OBJECTIVES/HYPOTHESIS:Over the past decade, thoracic slide tracheoplasty (TST) has become the principal operation in the management of congenital tracheal stenosis. The purpose of this report was to describe our experience with revision TST following unsuccessful prior tracheal reconstruction. STUDY DESIGN:Retrospective analysis at an academic children's hospital. METHODS:Patients undergoing TST on cardiopulmonary bypass between January 2005 and May 2014 were reviewed. Patients with a history of prior airway surgery were extracted for further analysis. Preoperative patient variables and postoperative outcomes were evaluated and compared between patients undergoing revision slide tracheoplasty (RTST) and a control group of 26 matched patients undergoing primary surgery TST. RESULTS:Twenty-six revision patients (25 referrals, one primary patient) of 162 patients reviewed over the study period met inclusion criteria. Twenty-three patients had a history of complete tracheal rings, and three patients had cartilaginous deficiency. A total of 41 airway reconstruction procedures had been performed prior to RTST. When compared to primary TST, patients undergoing RTST required fewer cardiac procedures intraoperatively, and fewer mean ventilator hours (P = .01) postoperatively. There was no significant difference in the median length of stay, requirement of >48 hours ventilation, or postoperative complications between groups. There was one nonsurgical postoperative mortality following RTST. CONCLUSIONS:Despite some differences in the postoperative management when compared to nonrevision cases, revision TST can be successfully performed after prior tracheal reconstruction with good postoperative outcomes. LEVEL OF EVIDENCE:4. Laryngoscope, 128:2181-2186, 2018.

Cavernous sinus thrombosis is a rare but well-documented complication of sinus disease, propagated by intracranial spread of infection via valveless veins of the midface, with facial cellulitis as an uncommon source of infection. We present a case of significant intracranial thromboses secondary to nasal dorsal abscess after trauma that was successfully treated with bedside drainage of the abscess in addition to broad-spectrum antibiotics, anticoagulation, and steroids, and remains asymptomatic with seven months follow-up.

OBJECTIVES/HYPOTHESIS:Evaluate and compare surgical outcomes of slide tracheoplasty for the treatment of congenital tracheal stenosis in children with and without pulmonary malformations. STUDY DESIGN:Retrospective chart review at a tertiary care pediatric medical center. METHODS:We identified patients with tracheal stenosis who underwent slide tracheoplasty from 2001 to 2014, and a subset of these patients who were diagnosed with congenital pulmonary malformations. Hospital course and preoperative and postoperative complications were recorded. RESULTS:One hundred thirty patients (18 with pulmonary malformations, 112 with normal pulmonary anatomy) were included. Pulmonary malformations included unilateral pulmonary agenesis (61%) and hypoplasia (39%). Children with pulmonary malformations had a greater median age compared to their normal lung anatomy counterparts. Preoperatively, patients with pulmonary malformations more frequently required preoperative mechanical ventilation (55.6% vs. 21.3%, P = .007), extracorporeal membrane oxygenation (ECMO) (11% vs. 0.9%, P = .05), and tracheostomy (22.2% vs. 3.6%, P = .01). Postoperatively, patients with pulmonary malformations more frequently required mechanical ventilation >48 hours (78% vs. 37%, P =.005) and ECMO use (11% vs. 0.9%, P = .05). Pulmonary malformation patients and children with normal anatomy did not differ in terms of postoperative tracheostomy (16.7% vs. 4.4%, P > .05), dehiscence (6% vs. 0%, P > .05%), restenosis (11% vs. 6%, P > .05) or postoperative figure 8 deformity (6% vs. 3%, P > .05). Mortality, however, was significantly increased (22.2% vs. 3.6%, P = .01) in children with pulmonary malformations. CONCLUSIONS:Although slide tracheoplasty can be successfully performed in patients with abnormal pulmonary anatomy, surgeons and families should anticipate a more difficult postoperative course, with possible associated prolonged mechanical ventilation, ECMO use, and higher mortality than in children with tracheal stenosis alone. LEVEL OF EVIDENCE:4. Laryngoscope, 127:1283-1287, 2017.

OBJECTIVES/HYPOTHESIS:To establish the prevalence of abnormal vestibular test findings in children with enlarged vestibular aqueduct (EVA) and determine if these findings correlate with clinical symptoms, radiographic findings (EVA size and laterality), audiometric findings, and genetic testing in these patients. STUDY DESIGN:Prospective cohort. METHODS:Patients 3 to 12 years of age with hearing loss and imaging findings consistent with EVA treated at our tertiary care institution were sequentially enrolled from 2009 to 2011. The following six outcome measurements were analyzed: audiometric findings, EVA laterality, temporal bone measurements, genetic testing, vestibular testing (cervical-evoked myogenic potentials, posturography, rotational chair, and calorics), and vestibular symptoms. RESULTS:Twenty-seven patients with EVA (mean age 9.2 years, 48% female) were enrolled in and completed the study. Vertigo was reported in six patients. Twenty-four of 27 (89%) had at least one abnormal vestibular test result. Midpoint and operculum size correlated with directional preponderance (P = .042 and P = .032, respectively). Also, high-frequency pure tone average (HFPTA) correlated with unilateral weakness (P = .002). Walking at a later age correlated with abnormal posturography results. There was no correlation between EVA laterality and vestibular test findings. CONCLUSION:We found a high rate of vestibular pathology in children with EVA; however, the prevalence of abnormal vestibular test findings in this patient population was not correlated with vestibular symptoms. Enlarged vestibular aqueduct size, HFPTA, and walking at a later age were correlated with abnormal vestibular test findings. In view of these results, it may be prudent to consider vestibular testing in children with these clinical characteristics. LEVEL OF EVIDENCE:2b. Laryngoscope, 126:2344-2350, 2016.